UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 436-iv

House of COMMONS

Oral EVIDENCE

TAKEN BEFORE the

Health Committee

MANAGEMENT OF LONG-TERM CONDITIONS

TUESDAY 12 November 2013

NORMAN LAMB MP and DR MARTIN McSHANE

Evidence heard in Public Questions 231 - 315

USE OF THE TRANSCRIPT

1.

This is an uncorrected transcript of evidence taken in public and reported to the House. The transcript has been placed on the internet on the authority of the Committee, and copies have been made available by the Vote Office for the use of Members and others.

2.

Any public use of, or reference to, the contents should make clear that neither witnesses nor Members have had the opportunity to correct the record. The transcript is not yet an approved formal record of these proceedings.

3.

Members who receive this for the purpose of correcting questions addressed by them to witnesses are asked to send corrections to the Committee Assistant.

4.

Prospective witnesses may receive this in preparation for any written or oral evidence they may in due course give to the Committee.

Oral Evidence

Taken before the Health Committee

on Tuesday 12 November 2013

Members present:

Mr Stephen Dorrell (Chair)

Rosie Cooper

Andrew George

Charlotte Leslie

Andrew Percy

Mr Virendra Sharma

David Tredinnick

Valerie Vaz

Dr Sarah Wollaston

________________

Examination of Witnesses

Witnesses: Norman Lamb MP, Minister of State for Care and Support, Department of Health, and Dr Martin McShane, Director, Improving the quality of life for people with long-term conditions, NHS England, gave evidence.

Q231 Chair:Minister, thank you very much for joining us.

Norman Lamb: It is a pleasure. Am I allowed to take my jacket off?

Chair: Please do.

Valerie Vaz: Just the jacket.

Norman Lamb: Don’t worry, Valerie.

Chair: Dr McShane, you are extremely welcome as well. I would like, if I may, to lead off by asking where we are in the process of preparing a policy for dealing with longterm conditions. Our understanding was that this was being followed up within the Department of Health, that there was a commitment to publish a policy for how we deliver improved services for people with longterm conditions, and that has now been transferred as a responsibility from the Department of Health to NHS England. What effect has that had on the process? Is the team being transferred or is NHS England starting again? How is that transfer working?

Norman Lamb: Perhaps I can start and then hand over to Martin. There are two things I would say first of all. To be honest, the work that was under way was slightly out of sync with the changing architecture of the way the system works, and a conclusion was reached that it was properly the responsibility of NHS England. So all of the information that had been gathered as part of the process building up to the strategy has been passed to NHS England. None of that is lost, but it does more sensibly sit under the responsibility of NHS England to map out the way forward. Along with that, the Secretary of State has made it clear that he wants his personal focus next year to be on longterm conditions. As you will be aware, he has focused very much on the "Vulnerable older people’s plan", which will be published before the end of the year, but he wants to turn his focus-and inevitably I will be working alongside him on all this-to longterm conditions next year.

Q232 Chair: What is the difference between a vulnerable older person and an older person who suffers from longterm conditions?

Norman Lamb: There is clearly an overlap, isn’t there?

Chair: You have accurately predicted my thought process.

Norman Lamb: Clearly, there are lots of people who live with longterm conditions who are younger than the sort of scope of the "Vulnerable older people’s plan", which is primarily looking at people over the age of 75. But the view that the Secretary of State took was that, if you can try and get things right for frail elderly people, you can then learn important lessons for all other people who might have similar complex health needs and whose care too often at the moment fails because of-as we have discussed many times-a fragmented system where people fall through the gaps, breaking up the continuity of their care. These things will, ultimately, all move in the same direction of policy, with the idea of an accountable, named clinician and the idea of a pretty fundamental shift towards a model of care, which is joined up and integrated around the needs of the patient. Whether you are talking about longterm conditions for people of any age or frail elderly people, the policy and the care solutions are rather similar, I think.

Dr McShane: Just to build on that, if I can contextualise it, there are the two big changes that we need to understand. One is that, as I would put it, we are almost a victim of our own success. We have seen huge improvements in health, life expectancy and longevity across the UK and in England. The problem that that has created is that, as people live longer, they are also developing both longterm conditions and frailty. Now we are trying to create an understanding that frailty is a diagnosis, not an adjective-that you can be frail because of your age without it necessarily being accompanied by longterm conditions. So it is a "both and" issue. It is quite right that the definition of "vulnerable" is both people with longterm conditions and people with frailty.

The other big context change is that we have done very well on health and planned care, but the system we have created does not really address longterm conditions and these are now dominating the consumption of resources in both health and care, of which I am sure you are fully aware.

From my perspective, longterm condition management needs to be integrated with everything else that we are doing. That is why, as one of the domain directors, we have started to model the way we work in the way that the system should work so that we are working as a team. If we take the proposition that the vision for NHS England is to deliver high quality care for all, we have the legacy of the Darzi definition of quality, which is safe, effective care, which gives a positive patient experience.

Effective care has been divided into three components: preventing premature mortality or avoidable deaths; enhancing the quality of life for people with longterm conditions; and helping people to recover from acute care or episodes of trauma. Those components are three of the five domains that lead to high-quality care for all and form the NHS Outcomes Framework. My role is to provide leadership and a narrative, and to look at the system levers and enablers that will enhance the quality of life for people with longterm conditions. But I am also dependent on the work that is being done in Domain 1 on reducing premature mortality and working closely with Keith Willett-I am sure you are aware that there is an "urgent care" review going on-because everything that happens in longterm conditions has an impact on emergency care as well.

We have to try and create a system that looks at a system, not just its different components. We have had a system that has focused very much on hospitals and we have had this mantra about moving care out of the hospital. I do not think it is about moving care out of the hospital. It is about creating the right care in the community so that people do not need to go into hospital. That is the agenda we are facing and which we need to tackle. To do that requires a huge cultural change, which is the biggest change.

Q233 Chair: Can I bring you back to my original question, which was a relatively narrow process question? Are you supported by a team that was previously in the Department? Are you starting again? We have been talking about the need to remodel services for people with longterm conditions since I was Secretary of State and that is a very long time ago.

Dr McShane: We have taken a very different approach. When I came into this job I discovered there were three different teams in the Department of Health addressing longterm conditions. We have set up the five domains and we have created crosscutting programmes across each of the domains to support improving quality of care for people across the whole context, as I have described. If you like, my team is very small but my resources are very large. So I work in a crosscutting way with all the other directorates in NHS England-patients and information, finance, commissioning development and operations-to make sure we have a clarity of purpose, a clarity of direction and we are focused on making those system changes.

Q234 Chair: I will have one more go. When are you going to publish an outcome from this process?

Dr McShane: We already have published a number of documents. On the NHS England website there is the narrative around quality. We have published the narratives for each of the domains and have already started to publish some of the tools. But the traditional "Let’s publish one strategy which says how we are going to deliver longterm condition management" is not our approach. It is about how we move the whole system to ensure that people with longterm conditions get high-quality care as well as delivering changes to premature mortality and hospital care.

Q235 Charlotte Leslie: Dr McShane, the overarching objective in Domain 2 of the mandate, for which you are responsible, is that the NHS should "make measurable progress towards making the NHS among the best in Europe at supporting people with ongoing health problems to live healthily and independently, with much better control over the care they receive." What is your assessment of progress against that and how on earth are you measuring it?

Dr McShane: First of all, I think we have made good progress, and let me give you one example of where the new system might differ from the old system. We have recently had the national audit report for diabetes published, which says that, in terms of care processes, we could do better. The "Global burden of disease", which was published in the autumn last year, with followup articles in The Lancet and a Canadian study, show that, benchmarked against the rest of Europe, we deliver the best outcomes for people with diabetes. When we look at the change in premature mortality for people with diabetes, only one country has done better than us, and that is Canada. So process is really important, but for too long we have completely disconnected it from purpose. We have not understood what the outcomes we are trying to deliver are and the measures of progress we are making. That is a huge step forward and we are probably the first country in the world to make that step. Other countries are looking at us to see how we do with it. There is a great deal of interest around it.

We are now working with the analysts to look at a whole range of new analytical measures. For instance, in the survey that is done annually for GP practices on patient experience, we have the EQ5D. Don’t ask me to explain it. It is a measure of what quality of life people have and I think it goes from 0 to 5. The 0 means dead, but I discovered that there is a negative measure as well.

Dr Wollaston: Worse than dead?

Dr McShane: Yes, working for the-no.

Charlotte Leslie: Being on a Select Committee.

Dr McShane: Anyway, measuring that, we are starting to understand what those factors are that correlate with improved quality of life for people with longterm conditions, because 52% of the people who responded to that survey selfdeclared that they have a longterm condition or conditions, which is becoming more prevalent. We are now starting to tease out what the measures are that we can put in place that show that doing this improves someone’s health and care.

Q236 Charlotte Leslie: So it is a sort of "work begun but very much a work in progress".

Dr McShane: It is absolutely a work in progress because it is a fundamental change in the way that we tackle improving health, given that the nature of the challenge to health care has so fundamentally changed itself.

Q237 Charlotte Leslie: Moving on, the mandate also requires particular progress in four key areas for longterm conditions. They are involving people in their own care, better use of technology, better integration of services and better diagnosis, treatment and care of dementia by March 2015. What is your assessment of progress in those specific areas and what do you think they will have delivered by March 2015?

Dr McShane: If I take those in reverse order-so I do not forget them-with dementia, the issue is that we have a national clinical director for dementia, Alistair Burns, who has provided continuity of care through the transition. We have, I think, first of all changed the nature of the debate. We have put measures in place. We are working assiduously on better measures to track quality improvement. We have, over the last two to three years, vastly increased the number of people who receive a timely diagnosis. It is a bit of an uphill struggle because the more people we diagnose, the more our estimated prevalence goes up at the same time. The denominator is changing almost as fast as the numerator. If we look at absolute percentage changes, we are seeing 10% or 8% changes year on year in absolute numbers diagnosed, but that is not being reflected in the ratio because of the change in prevalence.

Also, we are now working with the Alzheimer’s Society on what is critically important for longterm condition management-all four components. Traditionally, we have just looked at the person and the professional. It is critical that we also look at the carers because the carers suffer a huge burden where people have longterm conditions, yet the culture-and, as a medic, I can say it-is kind of, "Oh, well, we exclude the carers from being involved." That culture has to change.

The fourth component is community. The work that the Alzheimer’s Society and the Prime Minister’s Challenge on Dementia are leading on dementiafriendly communities is incredibly important-that we change the stigma and perception relating to that. So in dementia we have made good progress.

On personalisation I would warmly commend-and, if it has not been submitted as evidence, perhaps we can have a late submission-"Transforming Participation in Health and Care", the document published by NHS England a few weeks ago. One of my ambitions is to make sure that people have much more control of their own care and ownership of it. That is not abandoning people but giving them authority to inform and influence their care.

There were four things, but I can only remember three now. The other one was integration and the Minister has led the push, which I am quite willing to surf, on integration and integrated pioneers.

Q238 Charlotte Leslie: Great. I have another quick one and you have semianswered some of it. Have you set out any other measures of progress against other indicators in Domain 2 of the mandate-the proportion of people, for example, feeling supported to manage their own care?

Dr McShane: Yes. Fortuitously, I was able to influence the GP Survey this year.

Chair: It was more than fortuitous.

Dr McShane: They had dropped the question on care planning and we went back round and said, "Actually, we need to have this reinstated," because I truly believe that people being involved in the decision making about their care is incredibly important.

Norman Lamb: Can I quickly add, in terms of measurement, that you will be aware as part of the Prime Minister’s Challenge on Dementia that one of the focuses is on the health and care system, and part of that is about diagnosis, as Martin has said? The overall position is still under 50%. So we have made progress, but we are still massively behind. By going to all parts of the country, all CCGs, and getting them to determine what they want to achieve by 2015, we have come up with an objective to get to two thirds of people with dementia diagnosed by 2015. There is a very clear measurable objective there. Progress is being made, but there is a long way to go still on it.

Q239 Rosie Cooper: Can I make some general observations, Dr McShane, on that which you have talked about? As somebody who is close to this currently, you talked about operating as a team, yet out on the front line the NHS is fragmented and nobody knows who their boss is. I used to work for Littlewoods and we started off with a hierarchical system that everybody understood and we did very well. Then a managing director came in who believed in matrix management, which is a little bit like what you have just reflected, in that everybody worked up and down as well as across. The organisation froze and nobody knew whose boss was who and who did what. I have to say that that is how the health service feels to me today.

A lot of people in the health and social care system talk often about care in the community-and I noted you used different words "the right care in the community"-but the truth is that, when you are out there and that system is fragmented, what you are actually saying is, "You are on your own." You get somebody who will dip in every now and again, but the reality is that you and your family are on your own. Of course, that is so tragic. To make an observation, in terms of cost, the cheapest patient is a dead patient, and talk is even cheaper. All I hear so often is people in senior positions talking. The Chairman talked about integration, and I hear it; I hear it; I hear it. The people out there want it if it delivers, but you actually do not see much change.

If I might give you an example-and I will put it to the Minister as well-for me, what is going on is that we are all being kept busy talking while, using figures the Treasury have issued, the NHS will be bust in three or four years. It is just not affordable. On those Treasury figures we are bust. Last week Sir David Nicholson was here and he agreed. He told us that the Integration Transformation Fund, using existing money stripped out from the health service and from social care, would be the cliff edge to reform. How is all that going on, when you are redesigning and you have got domains everywhere?

On the front line, let me tell you, my father has just been diagnosed as terminally ill and I am told that nurses will come and see him every fortnight, but they cannot possibly tell me when they are going to come other than "sometime on Thursday". What am I to do-sit around? What are all these families supposed to do? Are we to sit around waiting for somebody to come today? It is all talk. You are not delivering on the front line.

How do you change? All this is grand and keeping us busy, but I still do not know what integration is. I absolutely do not know what it is because I cannot see it. As hard as I look for it, I cannot find it. How do you make it different for the people who really matter-the patients?

Dr McShane: Okay, I think that sums up the problem and the challenges we face, so let me tell you how people are doing that in places. We need to learn from them and make sure we spread it and create the right infrastructure and national levers to give people permission to do that, because too often we have tried to direct the solution from the centre with a onesizefitsall approach, which does not recognise that Barnsley, Basingstoke and Birmingham are completely different places and require different solutions depending on their populations, health needs and also the type of infrastructure that they have.

If I talk about accountability, one of the things that are absolutely right is having a buck stop. When I was a practising clinician working in the field-and I have worked for over two decades as both a surgeon and a GP-I felt that accountability for my patients. There has been some sense of dilution of that, and the current proposals to create accountability-a named person who is responsible for ensuring that care is co-ordinated and planned well-is a step in the right direction.

On the second point and your statement about matrix management, what I described, I hope, or intended to describe, was programme and project management. My insight and understanding of that is that, if you want to make change happen, if you have good programme and project management in place, then it happens. That is what we have set up. We have set up these programmes of work and they have clear accountability. For instance, we have just established the parity of esteem programme board within NHS England. Lord Victor Adebowale has kindly agreed to chair that, and I, as the domain director, am responsible and have a clearfelt responsibility for making sure we deliver in that area.

One of the things to recognise is what Chris Ham described in the health system as the inverted pyramid of power in that we are dealing with a professional system. It is the professionals on the front line who make the decisions on a daytoday basis. We have tried to overprescribe how they should do things, rather than trusting to their professional experience, knowledge and skills, and focusing on outcomes.

I will give examples of places I have visited in the last seven months since this organisation was established-and we have been going for only seven months, I would like to point out. Tower Hamlets a few years ago introduced a model, which I have nicked from them, called the House of Care, which took them from being the worst performing in terms of longterm condition management to the best, audited, in the UK within three to five years. I have been to Liverpool where the CCG there set out a new form of GP specification which meant that, in terms of being benchmarked against other areas, they are seeing reduced emergency admissions. I have been to Newark and Sherwood where the integration between general practice and the community and mental health team, end-of-life care, social care and the third sector is there. I spoke to a GP and asked, "What difference does this make to you?" and she said, "It means that when I go in and see someone in their house I do not say, ‘I am sending in a social worker and a district nurse to see you some time in the future,’ but rather, ‘I have rung Jane and Jack and they are coming to see you this afternoon,’" because they work as a team. So, yes, we are not there, but that is the direction of travel. That is why we need to make the changes that are being proposed and included in all the levers that we have.

Q240 Rosie Cooper: Okay, I hear that. You mentioned Liverpool. That is where my dad is. Let me tell you-I will truncate this dramatically-that he is falling; he is taken to hospital; he goes in to ward 2A, which is the community ward, and falls in the hospital. Useless. And I say, "Why is he falling? I need to speak to a doctor," and they say, "No, this is a community ward. You do not get it in a community ward." I say, "No. Why is he falling down? Is he in the appropriate place?" Then they say, "This is a community ward," and then I say, "The Secretary of State says there must be a named doctor." The response from those professionals you have just talked about was, "Even in the community?" If Liverpool is somewhere you are proud of, you need to get back there pretty darned quick and stay there because it is useless.

Norman Lamb: First of all, the example you give from your own family is an example of very poor care. We have to be very open about that and there is too much of it. We have ended up with a completely fragmented system, as you describe. Over the years, and I made the point, we have managed to institutionally fragment mental health from physical health, which, from the patient’s point of view, often makes no sense at all. Primary care is separated institutionally from secondary care-and health care from social care. So it is a horribly fragmented system and the principle of integrated care does not have to involve organisational change. It is about the model of care. It is about meeting the needs of the patient and shaping the care and the needs of that patient.

I was in Barnsley last Thursday and I would encourage you to go to somewhere like that just to see it on the ground if you say, "Where is it?", "I do not understand it," and so forth. There are these places where they have really got it. I met with the chair of the CCG, together with the leader of the council, the chief executive of the acute trust and someone from the mental health trust, all working together achieving a sort of systemwide, joinedup approach to patient care. It is quite inspiring when you see it, but it is the exception, not the rule.

We have identified-we may well come on to it-and announced two weeks ago 14 pioneers around the country who will push the boundaries of what is possible. I think everyone recognises that there are too many failures of care, and the way the health system is designed does not meet well the needs of people with longterm chronic conditions-often quite complex, often a mix of mental and physical health-and it has to change.

Chair: I think that is it.

Q241 Rosie Cooper: I very much welcome that but we have to do less talking and more doing.

Norman Lamb: That is why, in a sense, I got on and did. The interesting thing is that, when I invited expressions of interest for the pioneer programme, 99 local health systems came forward wanting to be part of it. We have identified 14, which I think are the real exemplars. They have been through quite an exhaustive process with an international panel, but they are getting on with it and doing it. I want these people to be leaders of change, not for the rest of the system to stand back and wait for five years to see what the result of a pilot is. We are going to constantly evaluate this. There is going to be a proper scientific evaluation from the start so that we can learn lessons all the way through the programme.

Q242 Andrew Percy: That segues nicely into my questions that relate to these pioneers, who the Department says are going to be "exemplars to support the rapid dissemination and uptake of lessons learned across the country," which, in English, I think means we are going to see how they do it and then try and copy them and do it quickly. What is the ambition of the Department in terms of the scale and pace of learning from these pioneers? By 2015, what percentage of the public, of patients, do we expect to be in receipt of proper integrated services?

Norman Lamb: The first thing I would say is that there is now very much a shared vision across the health and care system, the Department and NHS England-all of the players. Everyone recognises that we have to change this model of care to meet this particular growing need of people with chronic conditions. It is happening internationally; this is not something that is unique to the UK. I went to the States and saw some brilliant integrated care organisations at the end of May. There are great leaders all over the world changing and adapting the way their health systems work to meet this 21st century challenge. There is a momentum now to make things happen quite fast. So you have the pioneers out in front, but at the same time we have announced this £3.8 billion transformation fund, which Rosie-what am I supposed to-

Rosie Cooper: "Rosie" will do fine.

Norman Lamb: -has referred to. That comes into effect in 201516, but we are asking every area-the local NHS, the CCG and the local authority through the health and wellbeing board-to draw up their plans now. The plans will have to be finalised by, I think, February next year, and the idea then is that they start to implement this new approach ideally now, but we want it really in place by 201415. Then the transformation fund applies from 201516. This is a sort of wholesystem change, and it will require every area to draw up a plan of how they will use their share of the £3.8 billion fund. The interesting thing is that, when I met with some directors of adult social care a couple of weeks ago, they were all saying, "We are looking at pooling the whole of our budget, not just that 3% element that the £3.8 billion represents." You need to have the CCG to share that ambition, but it was fascinating that that is what they were thinking about-that the sort of catalyst appears to be driving some quite radical thinking about how you can pool resource locally, and I totally welcome that.

Q243 Andrew Percy: It would be interesting to see this scientific study of the pioneers, but the one thing that concerns me is this. We have been down this path in the past before in my local area when we tried to do it through mental health services in about 2008 and there was a push to community care. In my area the beds went, mental health wards were closed and it was all focused on care in the community. However, what we still find is that everybody talks about integration and about proper community services, but, at the end of the day, the only two services that are there 24/7 are the local hospital A and E department and the ambulance service to get you there.

I am interested in how this is all going to work out, because if we are going to have proper community care services-and we have this going on in my area at the moment, where we are trying to put an intermediate care centre in my constituency, costing £3 million, and it is very welcome-it means that social care has to be there 24/7. It also means that GPs have to be there and accessible, whether that is weekends, evenings or whatever. But of course whenever we get to the point of saying, "This is what we need," it then comes to a question of, "Who is going to provide the money for it?"

So we are having a debate at the moment about trying to extend GP services in my area, but it instantly turns into an argument, "But we want more money to do that." How do we avoid that? The hospital is not going to need less money, and social care still needs the same funding, yet the doctors and GPs are saying, "We want more money as well to remain open longer." How do we deliver proper community care services when they still end up with the problem of people arguing over their individual budgets?

Norman Lamb: The truth is that too many people end up in hospital inappropriately and unnecessarily-frail elderly people. About a third of people in a hospital these days are frail elderly people, often with dementia. Often they are there because of failures of care. If you can get the response much better in the community, supporting people in their own homes, then you can prevent those crises from occurring. Kaiser Permanente in California, for example, whose hospital in San Francisco we visited, has something like 200 beds occupied. Their bed utilisation is massively lower than we have here because they are much better at preventing crises from occurring in the first place. That has to be, I think, the focus of our minds. Ultimately, by shifting the investment from the sort of repair end to the prevention end-and there does have to be a shift-

Q244 Andrew Percy: With respect, that is what we are always told. That is what we were told when we had this with mental health services, but when people are in crisis the burden then ends up falling on the family because that has not happened. We have not seen that shift. It is great, and I buy into the concept and absolutely accept that we need to see it, but too many examples of where we have tried to do this locally in my area have resulted in-we have not had the shift-beds going and services being taken from the hospitals but not being replaced with community wraparound care. Instead, it is the family who ends up bearing the burden.

Norman Lamb: I agree and I am not claiming that this is easy, but first of all you have to agree what the vision should be and I think we are probably agreed on that. The £3.8 billion does represent a real shift-not talked about, but a real shift-from repair to prevention. It is shifting resources to prevent deterioration of health.

If you go to Hertfordshire, for example, within their existing resource I visited a 24/7 care response team that responds to crises in the community to make sure that someone does not have to be rushed into a remote hospital but can be looked after and supported at home to prevent that disruption to their lives from happening. There are examples all over the country. This is an early stage in the development of this but there is lots of evidence. Stephen, we were on a panel together last week and you made the point that Torbay always gets mentioned. That is because they are good.

Chair: It was 29 minutes today.

Norman Lamb: Yes, and that is probably a record. I have been trying to avoid it but I cannot. They have demonstrated on their statistics reduced crises, emergency admissions and bed utilisation and so on.

Q245 Andrew Percy: I understand all that. I just wonder, given the pace and scale of this, how you achieve that in such a short period of time? Hospitals have to make their Nicholson savings at the moment so they are under extreme pressure on that. My local hospital had to open up 100 extra beds last year to deal with the crisis in urgent care admissions. We only have a certain pot of money-there is not extra cash really-and we almost need to run both systems alongside each other, because there is not this cutoff point where people suddenly stop presenting at the hospital and there are fantastic community care services and all the rest of it. To provide one you need to take money from the other, but that does not end the pressure there. So I am not seeing where the money is going to come from in my local health system to move from one to the other seamlessly. You almost need an overlap.

Dr McShane: You are right about the overlap and people are looking at what sort of transition funding might facilitate that sort of change. I have had to think about this as the £2,000 per head on average that we have to invest in health for people. So a person has £2,000. If we look at the way that is split up-these are rough figures and I have made them simple so I can do the maths-about £200 goes into primary care; about £500 goes into community and mental health; £1,000 goes into the acute sector; and £300 goes into specialised commissioning. Up until 2010 I lived through the golden era of the NHS, when we had a yearonyear increase in funding, and after the 1980s and the early part of the 1990s it was a pleasure to be a clinician in the NHS. However, that stopped in 2010. If the acute sector goes up by 4%, the gearing in the system means that we would have to take 20% out of primary care to make it sustainable, or 8% out of community and mental health.

Reframing that, if general practice, community and mental health worked in a coordinated, coherent and consistent fashion, could you take 4% out of the acute sector safely-that need for 4% in the acute sector? That is a big ask, but we now have the clinical commissioning groups, which are membership organisations. We have a realisation among the profession that, if they do not address this in a coherent way, the decline in investment in primary care, which has diminished relatively over the last eight years in the NHS from 10% to less now than 8% of the share of NHS resource, will continue. If you look at that change, why are people surprised that we have problems of hospitals becoming flooded? All the evidence shows that, if you invest in primary care and community care, you reduce demand for the acute sector, but, because we are very hospital rather than system-focused, we have allowed it to drift that way.

We are looking at the financial levers, the quality levers and the information to support local communities to do what Rosie Cooper has asked us to do-to make things happen. A huge amount of work has gone on in the last year or so to do that, and we are seeing examples of how that can be applied and putting up opportunities. I would say that the pioneers are at the leading edge, but I was talking to someone this morning who said they just want to be a first adopter. The professionals out there recognise and understand the scale and nature of the problem. Many of those places that we always quote, such as Torbay, came about because of financial crises in that local community, which made people realise they had to do things differently.

Norman Lamb: In Greenwich, another of the pioneers, they reckon they have saved 2,000 admissions to hospital in their first two and a half years of operation. The local authority has saved £1 million just by coordinating things and also making very significant use of the voluntary sector. Voluntary sector and people-communities-have to be partners in this. We will not do it without the power of the wider community.

Chair: Lots of people want to make very short interventions. We will have Andrew and then Rosie very quickly.

Q246 Andrew Percy: I have a final question on this. As to "the golden years", I am not sure we would consider them as such locally when we were losing lots of services. Similarly, surely that was the time when this should have been done, when there were bigger increases, and it is a shame it was not.

But just to go back to the start of the question, what percentage of patients do we expect to be in receipt of proper integrated services by the end of 2015?

Norman Lamb: We set an ambition to get the whole system fully integrated by 2017. That was when we published the shared ambition or whatever it was called-I cannot remember the title of it-when we launched the pioneer programme back in May. That was the sort of ambition we set. This has been given quite a turbo charge by the £3.8 billion transformation fund, so by 2015 the whole country will be starting to see a significant change. It does not all happen overnight, but there will be significant changes happening by then.

Q247 Chair: Dr McShane, did you want to come in?

Dr McShane: In terms of integration, the common thread that comes out time and again is the fact that the places that are successful share information about the person and the person also knows that is happening. One of the things that in the NHS we should be able to do-and it seems to be quite difficult to achieve-is to share. We have the most computerised GP records in the world. We have the ability to share care records. We need to move that. What truly creates integration for people is the fact that the professionals and the person know what is supposed to be happening to them, there is a care plan there and they can understand it. In London, for people who are terminally ill there is a process called "Coordinate My Care", where, with the patient’s sanction and agreement, their care plan is loaded on to a web portal that can be accessed by services that they may require.

Norman Lamb: Including the ambulance.

Dr McShane: That includes the ambulance, hospices and so on. The number of people who die in their preferred place of death in the "Coordinate My Care" programme is 77%. The national average is less than 50%. So it can be done.

Q248 Rosie Cooper: I have a very quick question to the Minister. The ITF is currently standing at £3.8 billion. I am delighted to hear, or I heard you say, that an organisation-and I cannot remember which one, which is the reason I am faffing there-said they would be happy to pool a lot more resources.

Norman Lamb: I will come back to that when I answer.

Rosie Cooper: I have been trying to look at the figures for all this to try and get a handle on what is the future of the health service, where we are going to be. Looking at some numbers I have seen recently, they say that this ITF-that whole area-is projected to be around £59 billion and it should, properly integrated, release around £20 billion, but that £20 billion is to go to the Treasury, not back into the health service. Are those figures that you are familiar with?

Norman Lamb: I am certainly not familiar with that and I would be horrified if it went to the Treasury. Have I said the wrong thing?

Chair: They are everywhere.

Norman Lamb: Basically, the overall picture is that we have maintained funding for the NHS throughout this Parliament and for 201516, but the problem is that health costs are rising at about 4% a year, so even if you have protected funding for the NHS, even with a slight increase, it is not sufficient unless you make the money go further because of this rising demand. That is why you have to free up resources to meet that rise in demand, not to hand back to anyone else.

Q249 Rosie Cooper: May I write to you and show you the documents and figures?

Norman Lamb: Yes, absolutely. I know that the "total place" or "community budgets", or whatever they are called now-the DCLG plan-have some quite dramatic figures about the savings they believe they can achieve by pooling the resource that they have locally to use it in a more rational way. The trouble is that the evidence about savings from integrated care-a joinedup approach-is still emerging. That is why the evaluation of the pioneers is really important. But the starting point is that it provides better care. At the end of the day, all of us ought to be interested in that joinedup care that your dad clearly is not receiving.

Rosie Cooper: Forgive me, just to make it clear, the nurses were wonderful. The organisation and the management are absolutely awful.

Q250 Valerie Vaz: I have a quick point on pioneers. Minister, welcome. I think this is the first time you have come before the Committee.

Norman Lamb: It is. It is the first time I have been before any Select Committee.

Valerie Vaz: I did think that. Anyway, we are not as bad as people make out.

Norman Lamb: So far so good.

Q251 Valerie Vaz: We just try to get to the truth on behalf of the public. I want to ask you about the pioneers. It may be in some written documentation somewhere, but could you tell me what considerations you took into account when you picked these pioneers, and did they get any money for it?

Norman Lamb: The fascinating thing was that we were not offering any extra money and yet 99 areas of the country came forward wanting to do it, which is quite instructive. The way I see it is that you have a lot of great people doing amazing things around the country despite the system rather than because of it. They often have to fight through endless barriers to join up services, and it frustrates a lot of people and a lot of them do not get there. These are the people who have managed to do it despite everything.

We set a number of criteria-which I will try to identify, but if I cannot find them before we finish I will make sure we send you a note-about wholesystem integration, ensuring that there was a commitment for the whole of that system through the health and wellbeing board to demonstrate how you can join up care in a more effective way.

We invited expressions of interest. We managed to narrow it down to 28 as a sort of long shortlist. We then had a panel, which included international representatives. We had someone from Kaiser Permanente, someone from Sweden and someone from New Zealand-there is great stuff going on in Christchurch, New Zealand. Every area came forward and did a twohour session with panel members in London, and it was a pretty robust process, which ended up with unanimity, including the international contributors, as to the 15 originally. Unfortunately, they had set a criterion that, if there was a hospital in special measures, it was not credible to have that area as a pioneer. So, very sadly from my point of view, west Norfolk, my own county, did not make it because of the Queen Elizabeth Hospital in King’s Lynn having difficulties. But we now have 14 that have gone through that pretty exhaustive process and they, as I say, can hopefully lead the way in trying to demonstrate to the rest of the country.

There will be a centre of excellence based in NHS IQ. I was very insistent that there must be experts in that centre who were there to remove the barriers to integration. Martin has talked about sharing information. There are horrific problems across the system with bureaucratic rules all over the place, which prevent rational sharing of information between professionals caring for someone. They need to be removed; we need to get rid of them. We need to redesign the financial incentives so that we do not incentivise activity in hospitals but rather get the hospitals to have a stake in keeping people out of hospital, keeping people healthier. We need to ensure that procurement rules do not get in the way of sensible joinedup care. The centre of excellence will be there to remove these barriers and to provide guidance on how to do it.

Q252 Valerie Vaz: Great; thank you. Were there any patients’ or carers’ voices on this international panel?

Norman Lamb: We had outside organisations. We had Nuffield-Jennifer Dixon chaired the panel-and also National Voices was very much involved in the document that we drew up about setting our ambition for what we are trying to achieve, and the whole thing has to be completely focused on the patient. This is all about-

Q253 Valerie Vaz: But none on the panel.

Norman Lamb: I do not think there were any involved on the panel itself, but they had been involved very much in the document that we drew up about what we are trying to achieve.

Q254 Valerie Vaz: We have all mentioned Torbay, but we do so because it exists, it has worked and we have been to see it and they love it in Sweden, Denmark and everywhere else. So I was wondering why, if it exists, it is taking so long to have this integrated service put through everywhere else. You have the good practice and it works. I would just add the section 78 regulations for you to look at, which I think they are finding very difficult. I know you have been to the House to put through the new regulations, but I think they are finding them difficult to operate-

Norman Lamb: Do you mean these competition-

Valerie Vaz: Yes, with integration and competition.

Norman Lamb: Okay. First of all, it is a bit of a paradox, in a way, that one might imagine that in a state system like the NHS everyone would be doing exactly the same thing and following best practice and so forth, but actually it is a bit anarchic. You have fantastic practice, but you also have people who just fail to follow the best practice. It is often quite difficult to translate brilliant practice like Torbay across the system. In a way, I go back to what I said earlier. The people in Torbay achieved it despite everything placed in their way-all these barriers. They worked their way through it. They created a care trust and made it happen. These were pioneering people and I have enormous admiration for them, but we have to make it easier to experiment and to develop models locally. My ambition, in a way, is to change it from a culture where you do great things despite the system, to the system encouraging experimentation. We also have to be prepared to take some risks. If you never take risks in trying new ways of doing things, you will always end up with mediocrity. We have to be prepared to experiment. There is a lot of diversity among these pioneers. In Cornwall, for instance, they have a very substantial involvement of the voluntary sector in addressing the problem of loneliness, helping with people’s wellbeing and keeping them out of the formal system altogether.

Q255 Valerie Vaz: That comes on to my next very short question before we move on, but I think Sarah wants to talk about this point. They seem to have a different population. The population coverage is quite wide and I am wondering what mechanism you are going to use to pull together the best practice for each one because they all seem to be doing different things.

Norman Lamb: That is very deliberate. I expressly wanted diversity. I did not want us to impose a model to say, "This is the way to do it," and, "Who is interested in doing it this way?" I wanted people to empower clinicians and managers at a local level to develop their thinking. They are the ones who know how to run services. Sarah will know this very well from all of her practice. The richness in that diversity will be of enormous value because we will be able to see what is working better and what is not working so well.

Q256 Valerie Vaz: You will be able to pull out consistent themes from it.

Norman Lamb: Yes, I think so, because there will be this evaluation from the start. It will not be a question of us publishing a report in five years. There will be a constant dissemination.

Q257 Valerie Vaz: When is the first lot of dissemination of information?

Norman Lamb: Exactly.

Valerie Vaz: No, when is it? When is it likely to be?

Norman Lamb: I want it to be constant. I want to create a sort of virtual network. We are having a launch event on 3 December, bringing all the pioneers together. I want them linked up virtually, but I want all of those who failed to get to the final 14 to be linked in as well. The fascinating thing is that all of those who failed to get there all say, "We are doing it anyway. The fact that we have not made it to the final 14 is not going to stop us. This encouraged us to get on and have the conversation locally. We are doing it." So it has generated a great deal of action; that is Rosie’s point about actually doing something. It has generated that activity locally because they have been given permission to do it.

Q258 Rosie Cooper: If I may say so, Kaiser Permanente is working with Southport and Ormskirk Hospital Trust to set up an integrated care organisation. I have not noticed the difference in three years. I say that on the record.

Norman Lamb: Rosie, I do not know about the leadership in that area, but if you went to Kaiser you would see how it could be done really well.

Q259 Dr Wollaston: I am delighted that we are having a "Torbayfest" today, as that is my patch, and I share your tribute to the enthusiasm of the pioneers there. Dr McShane, you mentioned that the successful places share information about their patients, but you will probably be aware that they have a specific problem in Torbay. They have had to stop doing their virtual ward rounds because of the issue of patient confidential data flows, so they appear to be going backwards in some ways. Despite numerous letters and conversations about this, we are no further on.

Could you, Minister, perhaps set out what is being done, because it is not just affecting patient confidential flow? It means that the GPs and the CCG cannot talk to each other on things like sharing information with alcohol teams in very many areas. This is causing real difficulties across the NHS, but, particularly when we look at what is happening in Torbay, who are renowned for their data sharing, it is going backwards. Is there anything that is being done actively to put this right?

Norman Lamb: This drives me crazy. We had some events as we were developing the "Vulnerable older people’s plan", and I attended and spoke at a conference in London and wanted to test it. I asked people in the Q and A section-these were a whole load of people from the health and care system-"Is information sharing a problem?" You would have loved the reaction; it was just overwhelming. So I went straight back to the Department and set about finding a way of removing this barrier.

My starting point was, is it legislative or cultural? Is it people being overcautious because they fear that they might be doing something wrong? I have the latest advice today, because I said I wanted it before the session today, on this issue about sharing between commissioner and provider. If a commissioner wants to do risk stratification, for example, or wants to commission well for people with learning disabilities or mental health, there needs to be some sharing of data, information. The advice I have had today-and we can copy it to the Committee-is that there is no legislative barrier; this is a sort of cultural thing where people are behaving overcautiously. What we need is very clear advice. The Caldicott review, which was published earlier in the year, was supposed, in a way, to give permission to share, but it has not had that effect. That is the honest truth of it.

Q260 Dr Wollaston: In fact, people have actively been told that there is a problem. You are saying there is not a problem but they are being told there is a problem. This has been going on now for many months and directly impacting on patient care. It would be helpful to set out for the Committee exactly what is the problem and how it is going to be fixed.

Norman Lamb: I was told first of all that it was the Health and Social Care Information Centre that was responsible for issuing advice. I am now advised that that is not the case. They will be providing highlevel advice for largescale organisations using data, but, for the purpose of advice to the system to practitioners and provider organisations, it is the Department and NHS England that have to collaborate to do this. I have made it very clear to officials that we have to publish advice as quickly as possible-this is an urgent priority-which will make it absolutely clear not that there is a sort of option to share but that there is a duty to share. To get good, coordinated care you have to share. Indeed, commissioners have to have the capacity to do the risk stratification that is central to any integratedcare approach for a whole population.

Q261 Chair: You did offer to share your advice with the Committee, to which I think, if we may, we would to like to say "snap", just in case anybody missed it in the transcript.

Norman Lamb: Thank you for leaping on that.

Q262 Dr Wollaston: I am sorry to press the point, but it is directly there in the update to Dame Caldicott’s guidance that there is a duty to share in the patient’s interests and that there is just as much harm by failing to share. But that was some time ago and is still not happening. Could, for example, the virtual ward round be confident that they could reopen tomorrow without a penalty, or are we going to have to wait for more guidance specifically?

Norman Lamb: On the basis of what I have been advised, I absolutely understand that that should be perfectly possible. What appears to happen is that local areas end up, because of a fear of breaching confidentiality rules-data protection rules-creating their own bureaucracy around the sharing of data, which puts impediments in the way, whereas it is not needed.

Q263 Dr Wollaston: But they were directly told to stop doing the ward round, so it was not just that they feared it: they received instructions that they could not do it.

Norman Lamb: Who gave the instructions that they couldn’t do it?

Q264 Dr Wollaston: The CCG were told that they could not carry on doing this.

Norman Lamb: By whom-NHS England?

Q265 Dr Wollaston: I understand it was from the information, from Chris Outram’s office.

Norman Lamb: I would love to get to the bottom of this. In a way, dealing with an example like that is a good way of perhaps addressing the problem. The centre of excellence that I referred to earlier for the pioneers, which will be available to Torbay, will be there precisely to unlock this sort of problem. But there is an urgency about this because it is, as you say, affecting patient care all over the place.

Dr Wollaston: Thank you.

Q266 Chair: Can I deal with another specific example, because I would like to turn, if I may, to the process of who is going to do all this? You have described, and we have been in many evidence sessions where we have heard, a verbal picture painted of how services would be better if they were more patient-focused, more integrated and so forth. I did a thought experiment in my own county of Leicestershire the other day going through the commissioners, all of whom have to cooperate to make this happen. We have three CCGs, two local authorities, NHS England as the holder of the primary care contract and NHS England as the specialist services commissioner. Those are the obvious candidates; no doubt there are other small players as well. Who moves the system from where it is to where it is going to be, and what are the constraints on them doing it?

Norman Lamb: The reality is that leadership in any area-are you talking particularly about how you achieve the change at a local level or are you talking about-

Q267 Chair: I am talking about one health economy and I think I listed seven commissioners, all of whom will tell you they have resource constraints and all of whom have different accountability mechanisms and so forth. The purpose of commissioning, surely, ought to be to achieve the kind of change that you describe, but each one of those commissioners is working in a silo with legal constraints on their ability to move resource from one silo to another, never mind the accountability constraints. My challenge to you is that we all embrace the picture but who holds the monkey?

Norman Lamb: At the local level, the CCG can, and in a way the health and wellbeing board has the potential to do so. The potential does not mean it is necessarily there yet, but it has the potential to bring people together, and the various commissioners that you talk about in your thought process in Leicestershire have the potential to pool their resource, expertise and ambition to work together to achieve that.

Q268 Chair: To interrupt you for a second, take one element of this. Primary care, we all agree, is an important contributor to this process. NHS England is bound by a national contract with the BMA. How does NHS England as the commissioner of primary care play its part in refashioning community health? That is difficult enough on its own, never mind coordinating all the other commissioners on this landscape.

Norman Lamb: I agree.

Dr McShane: There are a number of points there which I will try and answer. The first is that clinical commissioning groups bring together clinical leadership and membership at a local level of people who are at the front, if you like, and they can make or break the system in their behaviour.

The second point is that we have always had a problem over the last 20 years. I was a fundholding GP and, unfortunately, the reputation of giving finance to GPs to commission a system was tarnished by a few rogues in the system. We then had a situation where the 2004 contract came along and devolved, creating a business contract rather than a professional contract. So there has always been a bit of a problem about the governance of investment in primary care. Currently, there is work ongoing in NHS England around our primary care strategy and the way that we work with CCGs. The legislation has one key clause, which is really important-that both NHS England and CCGs have a duty to the quality of primary care. It is about NHS England and the CCGs working shoulder to shoulder on that, but it also creates an opportunity to ensure that the governance of investment does not become tarred in the way that it has in the past.

Then you have the specialised commissioning. I have worked in specialised commissioning for 10 years and it ain’t easy. We are now beginning to see what bringing together one system can do for specialised commissioning across England. There is still work to be done about reconnecting the levels of commissioning and, if you like, the skin in the game between specialised commissioning and commissioning done by CCGs, and then linked back to primary care. This comes back to some of the stuff that we are doing around changing the national, community and personal approaches towards longterm condition management, which we are talking about here, so that we create enablers at the national level, use the community resources, insight, intelligence and understanding, to work with NHS England and the CCG side by side, so unified on commissioning in that part of the system, but also then, as the Minister has mentioned, the potential of health and wellbeing boards.

Certainly, having been involved in commissioning for a long time, one of the big changes for me was a few years ago when we were told we had to commission some social care from health. That brought us to the table, made us talk to each other and think about how we could make sure we both got value for that. I think the Integration Transformation Fund will support that as well, and the accountability is for the clinical commissioning group. There is an accountable officer; there is an area director in each of those areas who will be responsible for making sure that they work with the CCGs and with the health and wellbeing board; and then there is the local authority, which has social care and all the other pertinent parts of a community that contribute to health and care.

I was talking to a CCG accountable officer this morning, who has done a lot of work on integration in the last few years, and they are now exploring what role housing has to play in improving care and how they can align their purpose with the local authority to make sure that that supports better care. If you want a "command and control system" we could have that, but we have been there and done that, and the nature of the challenge and the context have changed and we need to do things differently.

Q269 Chair: I agree with that, but I want somebody who is actually going to change things.

Norman Lamb: Can I add two quick points? In Barnsley last week the local authority leadership was saying to me that their collaboration with the CCG, with the doctors leading the CCG, was much richer and more effective than the old PCT because there was the clinical leadership there, which was encouraging and positive. But I have also been struck by some of the leading innovative CCGs saying, "We want to do things to primary care and we are frustrated by the fact that it is commissioned by NHS England."

I raised that with the leadership of NHS England, and they appear to be very much up for their area teams working-as Martin says, because there is that duty to do so-collaboratively with a CCG that wants to do things differently, to be able jointly, in effect, to commission primary care, for instance, to extend access or to improve outofhours support in that area, or whatever it might be. So there are mechanisms to achieve the change that you and I both desire.

Q270 Valerie Vaz: The Chair has asked the questions around commissioning support generally, but I want to push you on the dialogue you are having. I know you want to bang heads together, but what dialogue are you having with the CCGs to support them in the wholesystem approach?

Dr McShane: It is massive. It is a very new dynamic and, as I say and I will reiterate, it has only been going seven months so we have been through the storming of the transition and we are now in the forming. We have a commissioning assembly. It meets once a year but that brings together NHS England and all the CCG leads, and there was one held a couple of months ago, which we attended. But the most important thing about this is that the commissioning assembly is a virtual entity that exists for the rest of the year. In the last few weeks, when I have been trying to work out how I can get delivery done, I have used the rapid reference process with the CCG chairs and accountable officers. So I can posit a question, send it out through that network and get a response within hours or days, and that then informs decision making within NHS England. At the moment I am doing work on the House of Care model and iterating that with colleagues in CCGs-and not just CCGs, but in the colleges, with National Voices, NESTA, the Health Foundation and other people-to build a model that people understand and have helped create, rather than sitting here coming up with a model and saying, "Right, everyone go away and apply this because I think it is a good idea." We have a really strong interrelationship with the CCGs.

Q271 Valerie Vaz: Everyone knows where they are going. Do you have any examples where NHS England has supported a wholesystem approach? Can you give any examples of that?

Dr McShane: Yes. It is partly through NHS IQ. NHS IQ is "improving quality". As the Minister has said, they are supporting the whole integrated transformation movement. The other example I would give, for instance, is as to some of the enablers we are trying to put in place. I am trying to get the money out of the system and into the ground to support commissioning development for mental health. The national clinical director for mental health, Geraldine Strathdee, worked in London previously and established a commissioning development course for mental health, which ran with the CCGs. That has had an impact already in London where the CCG leaders who have been through that development course really understand the potential, the purpose and the wherewithal to commission mental health better on a whole system, both in primary care, community and specialist as well. Is that the sort of example you were looking for?

Q272 Valerie Vaz: Yes; I do not know. You have to give the example; I do not know the example.

Dr McShane: Off the top of my head, that would be a clear example. We are taking that, and, as you said about the early adopters, when I sat down with Geraldine earlier this year, one of our objectives was to try and ensure that that programme gets rolled out nationally and that we have one person in every CCG trained in mental health commissioning. We are making progress on that.

Q273 Valerie Vaz: One thing I need clarification on-and it is partly probably me-is that NHS England has commissioned specialist services. Is there an overlap with what the CCGs do in terms of longterm conditions? You can be both, can you not?

Dr McShane: Absolutely. Let me give you another clear example if I can find it. If you give me a second to shuffle through my papers, I wrote down the details this morning. If we can think about obesity, this straddles all three domains in effectiveness. The guys from safety and patient experience will kill me now. In Rotherham they established a service to address obesity. Obesity, we know, leads to a fivefold increase in diabetes, a triple increase in cancer risk and osteoarthritis and all the other problems. They set up a tiered system, with primary care interventions, and then GPs could make referrals according to certain criteria. Then, of course, there is the specialised commissioning service, which is bariatric surgery where you put constraints around someone’s stomach. They launched this two or three years ago. They have had over 7,000 referrals now and I think the cumulative weight loss was 14.7 tonnes.

Norman Lamb: What an awful thought.

Dr McShane: But, seriously, they predicted on their model, on their trajectory, that 67 people in 201011 would require bariatric surgery. They predicted that would be 78 in 201112. The actual numbers fulfilling the criteria for bariatric surgery were 33 in 201011, so there were 67 predicted and 33 actual. It was 78 predicted in 201112, 28 actual, and in 201213 they had 15 people go through for bariatric surgery. That shows why we need to take that wholesystem approach. In fact, the commissioning group for bariatric surgery has said that every CCG must have a level 3 intervention in place. The fact of the matter is that the reduction in bariatric surgery funds the level, and it is again this matter of shifting the money around and making sure the investment is there. But we have had 40 clinical reference groups set up in the specialised commissioning service, with lay representation on every single one of them. They have been doing the specifications, but they are clearly linking to and trying to forge better links with the CCGs about what the implications are, how there needs to be that connectivity and integration between specialised commissioning, and community and acute service commissioning.

Q274 Valerie Vaz: Finally-you might have touched on this earlier-what tools do the Department of Health and NHS England have to influence commissioning for longterm conditions?

Norman Lamb: First of all, from my side, and then to Martin, we have the mandate. This is the set of Government priorities that we hand to NHS England and it has some legal force behind it. They are under a legal obligation to seek to deliver the mandate. We can hold them to account against that mandate through our formal sessions that we hold with them, and then it is refreshed. The refresh of the mandate has been published today. The mandate is very strong on longterm conditions about the need for everybody, for example, to have a personal care plan that they have been involved in drawing up, just to give one example. Then, as well as the mandate, we can lead on initiatives. On the pioneer programme, for example, we have worked collaboratively with NHS England. They have helped to design and deliver it. Then there is the £3.8 billion fund, which, as you know, stemmed from the spending review, but then we worked with NHS England, and continue to do so, to deliver the detail of how you make sure the fund works as designed.

Dr McShane: If I can, I would like to try and capture all of this. This is why we are using the metaphor of the House of Care at the centre of the domain narrative for Domain 2, the one I lead on, enhancing the quality of life for people with longterm conditions, because it has four components and all of them have to be built if you are going to create personcentred care. The first component is commissioning. For instance, the Minister has been really helpful about his approach to trying to tackle the issues around risk stratification. When I went to Newark and Sherwood, they had used risk stratification not to identify individuals with problems, but to look at the total need of their population and then map what they were commissioning against that total need for the management of longterm conditions and see where the gaps were and what else they had to commission. So commissioning should be seen as a quality improvement cycle. Most people think of it as just procurement and contracting-and it is not. It is an art as well as a science.

The second point is the roof of the House of Care, which is clinical and organisational processes, such as NICE guidance. We are working very closely with NICE. For instance, again we had the opportunity to influence them and say, "The problem with your singlecondition approach is that the nature of the challenge in the health system has completely changed. People do not pitch up with one longterm condition. They are hunting in packs now." The second point is the two pillars that really hold this place up.

Q275 Valerie Vaz: It is the walls, isn’t it?

Dr McShane: It is the walls-empowered patients and carers. In the work that Tim Kelsey and his team are leading-and I am working on-one of our programmes is "Patients in control". We identified that in the domains, but we have actually said that Patients and Information-they took it off us-are leading that and we are supporting them. As to carers, we have a big carers’ workshop coming up in the next few weeks because we want to know what it is we need to do to create this at a national level.

Finally, there is professional collaboration. Longterm condition management requires continuity of care and there are three components to that. One is informational continuity- "The information about me is available wherever I go." We are now seeing with mobile technology the development of apps, which means that people can take their information with them. There was an 80yearold taken to A and E recently who handed over her iPad and said, "All my medical records are here. Would you like to use them?", which rather stunned the assessing clinician, but they did find it useful.

It is about professional collaboration. Continuity always requires that and management continuity, which we have talked about, but also relational continuity. This is where the named doctor comes in. Getting back to knowing who I can trust and turn to when I have problems with the care that is being delivered for me in the way that we have had so clearly articulated is not happening in places.

I also think that relational continuity is about relational continuity between professionals. When I was a GP, there was a coterie of incredibly useful specialists-not all of them doctors, some of them nurses-whom I would contact when I wanted help in managing the patients I was looking after in the community. It is about that team-working. In part, some of the incentives and financial incentives in the system, which are brilliant for planned care, just don’t work for longterm condition management. Competition and choice is great for planned care, but longterm conditions demand integrated care and that requires a new dynamic.

That is the model. I think there are components we can deliver at a national level, which have already been articulated; there is some of that that has to be delivered. But the biggest transformation is at the personal level. That is why we are working with the Royal College of General Practitioners, NESTA, the Health Foundation and others, to create a narrative and an understanding of how we support professionals and change the culture right at the coalface. I know I did not behave that way in the past and it is a big ask. So we are working with Health Education England on how we change the training and the skills that professionals have coming up for the future challenges, not the past.

Valerie Vaz: Thank you very much.

Chair: That is a neat leadin to Sarah’s question.

Q276 Dr Wollaston: You mentioned tariffs. That was going to be the next group of questions. You talked about levers quite a lot earlier, Dr McShane, and one of the problems in the NHS is that people tell me they pull the levers and nothing happens, be that a reconfiguration that is bogged down in bureaucratic and legal challenges at vast expense or something else. The other issue is tariffs and how we are ever going to shift this while hospitals can still hoover up the care through a tariffbased activity. Could you update us as to whether you agree that the tariff change is essential and what progress is being made?

Dr McShane: NHS England and Monitor recognise that tariff change is required to support the vision that has been set out by the Minister. We are already making progress on that. There has been a lot of work done on what we call the Year of Care tariff, which NHS England inherited and has continued. We are discovering some quite exciting information.

I was recently party to information from Somerset, which was an analysis done by York university, part of the Year of Care work, where they had analysed over 100,000 episode treatment groups, patients with longterm conditions. It illustrated two key points. One is they had 5,500 patients with diabetes in Somerset, and only 853 of them had diabetes alone, so multiple longterm conditions were the problem. Some of those are synergistic in medical terms, but some of them are nonsynergistic. It makes it very difficult to interpret NICE guidance if you have someone who has, for instance, asthma and hypertension and-

Norman Lamb: Depression.

Dr McShane: Yes, they will have depression, dealing with that. What they found in addition to the multimorbidity agenda, confirming the Scottish study, is that once you get above two or three conditions the average cost is dependent on the number of conditions, not the type of condition. So we are hoping we may get into a model that may be more useful and applicable in how we set a Year of Care tariff. But the evidence from elsewhere is that you need to set that across the whole system, linking the hospital, the community services and the general practice. There needs to be a proportionate risk for all those players. You cannot do it on an episodic, fragmented basis. The integration pioneers, the new planning guidance that will be coming out in December, and the joint announcement by the key national bodies will show the change in context for people, and the opportunity for people to experiment to use flexibilities locally to design different ways of incentivising the system. I think we are at a tipping point.

Q277 Dr Wollaston: Does it also highlight the issue that has come up several times about whether or not you split the NHS cake depending on age, which is, I understand, the greatest predictor of multiple-morbidity, or whether you split it predominantly on the basis of deprivation? If we are looking at needsbased or preventionbased care, what is your view on that debate?

Dr McShane: It is complex and interesting. The York study would show that in fact it is the number of conditions you have that is the biggest predictor of cost, not age. It is just a fact that, as you get older, you get more conditions. You have to remember that there are an awful lot of older people living really well, and that is the way I would like to go as well. Quality of life into old age can be very good, but, if you are 55 and you have multiple conditions, your quality of life will be as poor as if you are 85.

Q278 Dr Wollaston: Do you see eventually the NHS moving to a model that predominantly recognises the number of conditions people have as the main way that you distribute the financial cake across the NHS?

Dr McShane: Possibly, and I think there is still a lot more work to be done on that. The other thing we have to recognise is the emergence of frailty as a diagnosis, so you can be elderly and frail without multiple longterm conditions. John Young, who is our national clinical director for frailty and integration, has defined this and there are measures for it. We can send you a note on it; it feels like a viva voce at the moment. One of the key determinants is how fast someone walks. You can measure that in a GP’s surgery over 4 metres with a stopwatch.

Q279 Dr Wollaston: You can have a race with all your patients.

Dr McShane: But it will tell you the likelihood of something. That is a strong indicator of coordinated and proactive care being needed for that person. By the way, there are two things that drive huge cost into the system: one is dementia and the second is mental health. We have not really properly understood and tracked the importance of improving care for people with dementia.

Norman Lamb: The most expensive people of all in terms of their care costs are people with multiple chronic conditions, including mental health. That shoots up the cost and often the care they receive is very poor.

Q280 Dr Wollaston: So treating their mental health will improve costs across the system.

Dr McShane: Again, at Newark and Sherwood, when I talked to the team about the CPN that they had commissioned, because of their analysis of what was required in the virtual ward, within six months they had already identified that it would be a good idea to commission more mental health input, because when the CPN was going in to deal with someone’s problems, often with longterm conditions and anxiety, they were also supporting the family’s problems and the carer’s problems. There is a huge impact on the mental health of carers as well.

Q281 Dr Wollaston: Returning to the tariff for a moment, when would you estimate that we are going to have the new system in place? When are we going to have the certainty for those who are trying to plan services as to how the reformed tariff will look?

Dr McShane: First of all, there is a raft of flexibilities within the current system that people can use. I have used them in the past myself.

Norman Lamb: We are actively encouraging the pioneers to do it with support from the central team.

Q282 Dr Wollaston: So to decide how they use the-

Norman Lamb: Yes. We are saying to them, "If you want to redesign your payment systems, your incentives, so that your acute hospital has a stake in keeping people out of hospital, go ahead and do it, and we will encourage and facilitate you doing that." That then provides the learning for the rest of the system. As I understand it, there is work going on between NHS England and Monitor to redesign a national tariff approach, but there is this encouragement, not just passive acceptance, for areas to get on and experiment now, developing their own variations on that theme, using the Year of Care that has been developed. Four of the pioneer areas are areas where the Year of Care has been in place for some time in its development.

Dr McShane: They have been doing work on it.

Norman Lamb: It will be more of a nuanced picture as this starts to change, but the overwhelming need to change from a system that incentivises activity is clear to everyone.

Q283 David Tredinnick: Good afternoon, Minister. I want to ask some more questions about personalised services. You have already alluded to personal care plans, Minister and, Dr McShane, you talked about patients being in control. The Department has said in a written submission that there is a "fundamental shift in emphasis from a disease focused to a person centred system." We are all agreed on that. It is interesting to me, as someone who has been closely involved in complementary and alternative medicine here and chaired the Parliamentary Group for Alternative and Complementary Medicine for many years, that most complementary and alternative medicine practitioners, if not all, have always put the person first and the disease second. So, in a sense, that is now coming into the mainstream and is something that you might want to mark, because, with personalised budgets, I suspect that there will be more and more complementary and alternative medical practitioners involved as patients ask for those services.

The question I want to ask you to begin with is how are you going to support patients and carers in taking charge of their care plan and managing their own conditions?

Dr McShane: I think again-I am sorry-

Norman Lamb: Who were you asking?

David Tredinnick: I am always asking the Minister first, but I think, Dr McShane, if I may say so, you have done sterling work in support of your Minister in this session.

Norman Lamb: There are various things that you can do to help an individual manage their own care and take control, and we are often not very good at guiding and providing education for someone, for instance, with diabetes to be able to manage their condition much more effectively. We know that, if you do that, it makes a massive difference to well-being, but also helps to avoid crisis occurring in their care.

Along with that, I want to make the point about personal health budgets, something that I am a passionate advocate of. When I came into post last September, there was a plan in place to legislate to provide a right to request a personal health budget for people on NHS continuing care. I feel that that does not do enough to change behaviour across the system. There will be some CCGs that are very good at encouraging and facilitating people taking control, but there will be others who do not tell people about it and do very little to change the traditional way of doing things. So I wanted a "right to have" a personal health budget, not just "a right to request". That will come into force in October next year. In April next year there will be a legal right to request, ultimately for the CCG to say no, but from October it will be a right to have, obviously subject to some safeguards in cases where it proves impossible. It will be fundamentally a right to have a personal health budget, and I am very keen that we extend that beyond people with NHS continuing care. A prime area for me where I want to develop the concept is in mental health. If there is any area where we should be empowering people to take more control of their lives, surely it is in mental health.

Q284 David Tredinnick: I want to ask you further on about the lessons you have learned from the pilots, on which I had a very interesting presentation a while back. Do you think that all services users with longterm conditions will welcome a shift to patientcentred management? Have you done any-

Norman Lamb: I am quite sure.

Q285 David Tredinnick: Are they going to be frightened of the concept?

Norman Lamb: It was fascinating back in Barnsley again last week that they have pushed within social care the principle of personal budgets and direct payments further than many local authorities have done. The leader of Barnsley council was telling me that he was faced with lots of people saying, "This is the council abandoning older people and forcing them to take charge," and everything, but he said that it was amazing the extent to which older people, the very group who many people say will be resistant to being given the power, are just as enthusiastic and committed to it as anyone else. One of the big shifts that I talk about that needs to happen is from a paternalistic system, which I think the NHS fundamentally is, and indeed the local authority care system is, to one that is absolutely personal, where the objective is to give power to the individual to take control of their lives.

Q286 David Tredinnick: I will develop that in a moment, but I want to ask you first about primary and community care services which are being asked to manage models of care that are increasingly complicated and also individualised. How is it possible to design a service model that ensures that the patient’s needs come first with that slightly complicated background?

Norman Lamb: I do not think it is necessarily any more complicated involving the individual than imposing something on the individual as a passive recipient, ultimately. All of the evidence suggests that, if you engage and involve the patient, the person themselves, you end up with better results. You design that package of care to much better reflect their needs and what their priorities are than you do if you just impose it on them. I am not suggesting for one minute that this is easy, and some of the packages of care are highly complex-I absolutely accept that-but having a partnership between the patient and the professional must be the way to get the best results.

Q287 David Tredinnick: I put it to you that on personal health budgets the pilots that the Department ran were spectacularly successful. They showed, from the presentations I have seen, not only that the patients were empowered and costs reduced but also that carers were reempowered. Would you like to expand on that, as I see Dr McShane nodding? If you would like to elaborate on that, the basic question was what have you learned from the pilots?

Norman Lamb: We have learned that exactly. I have learned the same lesson that you have learned. What was quite interesting was that there were a number of areas of the country that participated in this, and where the maximum power was given to the patient to take control, the best results emerged. Where it was highly constrained, where it was constrained empowerment, the results were more limited.

To give you an anecdote, I was talking to a man from the Kent pilot, a wheelchairbound individual who had complex disabilities who had been in and out of hospital, like a revolving door in A and E. Once he had taken control and was able to determine what his priorities were about how his care was delivered and sorted, he had no longer been in and out of hospital. It had stopped. It was very moving to hear his story.

Q288 David Tredinnick: One of the aspects of the pilots was that those offering the pilot were not judgmental about the type of treatments that the individuals asked for. They were not offered a rigid range of options. That is my understanding. Is that right?

Norman Lamb: Yes.

Q289 David Tredinnick: In one instance a presentation from an official in the Department was talking about piano therapy, tai chi and even sports therapy that had been selected and approved, because the patient can choose what they like, providing it is safe.

Norman Lamb: We have to open our minds.

David Tredinnick:Really open them.

Norman Lamb: Yes. Let’s focus on what is the central principle in the Care Bill, which is well-being. We should not always be asking, "What service do we need to deliver to this individual?" We should be asking the question, "How do we enable this person to lead a good life?"

Q290 David Tredinnick: We had Arthritis UK present a memorandum to this Committee. They published two reports on complementary and alternative medicine in which they found that the 20 they looked at, the whole range, were fundamentally safe; they were absolutely safe. I put it to you that we are going to move into a period here where these patients ask for, increasingly, what used to be seen as complementary and alternative medicine and that the legislation and this policy is almost automatically drawing them into mainstream health.

Norman Lamb: That may well be the case. For me, it is about what matters to the individual and focusing on their well-being. We know that in mental health, for example, exercise, good diet, sleep and engagement with the outside world are all incredibly important principles. So we should go with what is important to that individual as far as it is sensible to do so.

Q291 David Tredinnick: I have one more question on that theme. When Professor George Lewith, professor of health research at the university of Southampton primary care department, gave evidence a week or so ago-I quote from the transcript-he said: "We know with cancer that people who use complementary medicine on their cancer journey, which is between 20% and 40% of people with cancer, get a huge amount of ability to selfcare and a lot of positive survivorship skills from using complementary medicine, not as a cure but as a longterm survivorship process."

I put it to you that this is where complementary and alternative medicine is going to play a major part in the Government’s plans for personalised budgets in developing personal ability to extend life and to feel happier in their state with their longterm illness.

Norman Lamb: I note the evidence that has been given and I do not in any way seek to contradict it. For me, it is not about the Government saying, "This is what will happen," or "This is what we want to happen." It is about giving people the power, with the objective of improving their lives. That must be what drives us.

Q292 David Tredinnick: What follows on from that is that we have to make sure that the resources for the different treatments that the people choose are readily available.

Norman Lamb: If you have personal health budgets for particular areas of care, such as NHS continuing care for those people with complex needs, I suspect that markets will develop for the sort of things that people want to use the money on. Where it is rational for the individual, we should not seek to overly constrain the way that money is used.

Q293 David Tredinnick: Chair, I have one last question. It has been suggested to us that personal health budgets could be joined up with local authority personal care budgets under certain circumstances, allowing integrated care at a personal level. Is this a funding option you are considering?

Norman Lamb: For me, in a way, the best integrator of care is the person themselves. If they are given some power in this, they will design what they need around their lives, making sure that it all fits together for them. The more we can move away from these awful silos that have existed-which in the past have been okay because the NHS, in a way, has focused particularly on episodic care for a particular problem, which is then sorted and the patient goes home-the better. Now that we are dealing with this dramatic growth in chronic complex conditions and people living for many years with them, the model has to change. To have these silos makes no sense from that patient’s point of view. If we can use the resource through personal budgets, bringing the two sides of the divide together, that seems to me to make absolute sense.

David Tredinnick: Thank you very much.

Chair: Rosie wants to ask a question, I think, about the impact of all of this on the acute sector.

Q294 Rosie Cooper: Yes. In essence, I was going to suggest we went back to the shared vision, but lovely warm words-

Norman Lamb: That sounds almost cynical.

Rosie Cooper: It is, I am afraid-very. The treatment of longterm conditions in the acute sector should actually be reduced substantially. If that is the case and we get towards delivering that, what would the effect on the acute sector be and has anybody made an estimate of the number of beds that we would need to take out of the system if that move to community care was successful?

Norman Lamb: I have not seen any estimate of numbers of beds involved. I want the incentives in the whole system to be aligned-and they are not at the moment. You have an acute hospital that is incentivised to do more, and that is not aligned with what people in community care are trying to do for their patients. We have to change that fundamentally. Under the last Government, the changes made to stroke care are a perfect example of how there was a recognition, from the clinicians first of all, that the way we were dealing with it was not good. People were dying unnecessarily or ending up with permanent disability unnecessarily. A change was made to focus on fewer centres, and probably hundreds of lives have been saved in London-just to take one place-as a result of that.

All this has to be driven by achieving better care. If we end up with fewer people going into hospital, as a result of keeping frail elderly people fitter and healthier at home because their care is managed better, and the voluntary sector is attacking the crisis of loneliness that we face in our communities, then that is great. That is a "good news" story and then the system needs to adapt too.

Q295 Rosie Cooper: As long as you are not home alone, of course.

Norman Lamb: That is what we need to tackle. That loneliness is what we need to absolutely tackle.

Q296 Rosie Cooper: Minister, it would be great to have a much longer conversation with you because there are things I could say that I should not say here, but that would be-

Norman Lamb: I am not sure what you are referring to there.

Rosie Cooper: The thing is that it is very difficult for people. The reason I used the example before of nurses not being able to say what time they were coming to see my dad is that he is deaf; he was born deaf. So without me or an interpreter, what is that visit about? He is one of those people who had a stroke who did not get the treatment. Although I got him into hospital within 40 minutes and I knew what should happen, he did not get a brain scan and thrombolysis was not given. In fact, the consultant on duty told me to my face that thrombolysis kills more than it cures. I asked him what his specialty was-he was in charge of the Royal Liverpool A and E that weekend-and it was diabetes. This was a few years ago, but it is an absolute disgrace and from there we move to today. I have a long frontline experience as well as-

Norman Lamb: I understand.

Rosie Cooper: So, when I hear all this, it is fantastic but it really has not changed a great deal.

Norman Lamb: I think stroke care has changed though; it really has.

Q297 Rosie Cooper: Yes, stroke care has changed fantastically, but what I mean is that interface. I will have this conversation.

Norman Lamb: I have been in the job a year but I have a very clear vision of what I am trying to do.

Rosie Cooper: Okay, and that is really great, but what I would say to you, clearly, is that there is a big difference between that which we think we are doing and that which is being delivered on the front line.

Q298 Chair: I want to bring Dr McShane in, but I want to help Rosie. One of your predecessors, Minister, Enoch Powell, when he was launching the hospital plan for the transformation of mental health services, was more direct in the effect on the oldfashioned mental health acute sector. He went to the contemporary equivalent of the NHS Confederation and told them to close 75,000 beds and not to err on the side of caution.

Norman Lamb: Wonderful. What year was that?

Chair: It was 1961.

Norman Lamb: Amazing.

Q299 Rosie Cooper: I cannot believe that you do not have in the Department of Health some idea of the numbers. Why do I say that? Because whenever you fashion a new hospital, with the PFI and all those numbers, you work out how many hospital beds you need. So you, or the Department of Health or NHS England, will know how many trusts have to go and how many beds have to go.

Norman Lamb: I am not trying to be difficult, or I do not have a figure in my mind that in a new world it would be, but I do recognise that when you go and see Kaiser Permanente you see a much lower bed utilisation in hospital because they are keeping people healthier, and that is ultimately what our objective surely should be.

Chair: Dr McShane, I promised to bring you in.

Dr McShane: It was really as an example of what could happen. So, small scale, a GP in Gnosall-

Norman Lamb: This is fantastic.

Dr McShane: -sends out a birthday card to everyone over the age of 75, and it just happens to have a comprehensive geriatric assessment attached to it, which he asks them to return. Because he has lived and worked in that community for so long, they do. He risk-stratifies his population and has used a mobile technology with the elderly and those with dementia to create a care plan with the carers and the community services, but he has also mobilised the community with volunteers going in and befriending people with dementia and supporting them. As a consequence, for just his one practice-benchmarked, again, against other areas-he has taken over £400,000 out of his spend for acute and social care.

It will have an impact on hospitals. I have worked in hospitals for over a decade. They are big places with lots of wards, and in each ward it is the staffing and the cost to the ward that has the biggest impact. So, if hospitals work with their communities and are part of the community rather than acting as if they are a community on their own, then we can shift these resources between those components to support the better care that people should be receiving.

Q300 Rosie Cooper: I hear that and think that is absolutely where we should be. But-of course there is a "but"-Dr McShane, you talked before of the elderly patient turning up with their notes on their iPad. Let me tell you what really goes on. In August my father falls; I am down south and he is taken to hospital. The Royal Liverpool A and E has no interpreter, so God knows how they made any sense of it. Anyway, I find he has been transferred to the community ward-fine. When I get there, I am very clear that no one-no one-could have read his notes because they do not have a clue. After I asked to see the doctor-the bit you heard before, and it goes on and on-a locum doctor opens his notes and says, "Oh, they stop in 2007."

Can you tell me how good clinical care, in an A and E and on a community ward, can operate with nobody noticing that they do not have all his notes? It took three days to get those notes. How is that good clinical care? It is an outrage.

Dr McShane: We totally agree with you, and your particular case is-

Q301 Rosie Cooper: It cannot be unusual. They are not all lining up just to pick on my poor lovely dad. This is going on with all the people about whom you are talking in this lovely idealised situation. It is not happening.

Norman Lamb: The technology challenge is enormous. I have had a chap in Norfolk admitted on a weekend and they needed to see his medical notes, but they were locked up in the GP practice. They could not get hold of them. They gave him aspirin twice that weekend and he was allergic to it, and it ends up with awful care. But we need, as a priority, to get all of these different parts of the system linked up.

Rosie Cooper: These were paper notes.

Dr Wollaston: Rosie, that is the question I am coming on to.

Rosie Cooper: I am sorry, Sarah.

Q302 Dr Wollaston: I am just saying that I think it is very important, Rosie. What you say comes to the heart of this. What progress are we making towards patients holding their own records so that they are transferable across the whole system? We are told that it will be by 2015. Are we on target to deliver just this kind of thing so that we do not have these issues arising again and again?

Norman Lamb: Do you want to answer that from NHS England’s point of view?

Dr McShane: Yes, I will. In terms of the infrastructure, the opportunity to deliver that and the work that is being done by Tim Kelsey’s team on-I have to use the word-intraoperability, notes can talk to each other and the deployment of the summary care record across the country covers 60% of the country now, I believe. We are making progress, I think, though this is a fundamental cultural shift that has to be addressed. We have to stop being scared of people having access to their own records. We have to realise that people with longterm conditions, especially, are partners in their care with professionals and need to be given that control. We are making the progress to enable it. Are we on target to deliver it? I am not going to nail myself to that right here and now because it is a massive agenda.

Q303 Dr Wollaston: Do we need to have a fundamental shift in who owns a medical record so that the patient owns their record? It is not owned by the Secretary of State.

Norman Lamb: Exactly.

Dr McShane: Yes, Sarah. There are two things. Where people are being given permission to do this, they are embracing it. As to the example I gave you, I know that people are trying to roll that out across whole CCG areas. I know that there is Patients Know Best and that there are areas where CCGs and local populations are embracing it. I cannot tell people to do this, because there are all sorts of problems and the reality is that, for some people, having access to and control of their own records may be dangerous if they are in abusive relationships or in circumstances where it could put them at risk. It is up to local areas to make the advances that are required to change the culture and to work with their local populations to do this. But are we giving out the signal from the centre and creating the levers and enablers to allow that to happen? Yes.

Norman Lamb: All I would add is that there does have to be an urgency and a sense from the centre that people have a right to have access to their records. It should not ultimately be down to a local area to deny that. There are other systems where on an iPhone you can get medical records, test results, book an appointment or have secure email consultations with your doctor. This is what should be happening. In Seattle, Group Health-a fantastic notforprofit integrated care organisation-by extending massively the number of patients who consult their GPs by email, frees up the GPs’ time in order to deal with those really complex cases that need more than the ridiculous 10 minutes that many GPs have at the moment to try and resolve complex problems. The evaluation of this transformation in one clinic in their system was dramatic. It resulted in massive improvement in patient satisfaction, but, interestingly also, a very significant improvement in quality of life for the clinicians, because the pressure was taken off them, and they were able to work in a more rational way and devote more time to the complex cases.

Q304 Dr Wollaston: Do you think part of the problem is that we had our fingers burned by the cost of Connecting for Health and that it did not deliver?

Norman Lamb: Yes.

Q305 Dr Wollaston: How is that going to change? How are we going to get a system that-

Norman Lamb: The national programme has been a disaster. We have spent billions of pounds on it. The NHS is caught in a time warp. When I hear that faxes are still flying around the NHS, I wonder what other sector of the economy that happens in.

Chair: The Inland Revenue.

Norman Lamb: Did you want to say something?

Dr McShane: Very briefly. It is already happening in places. We are at the bottom of the Scurve of change. All the patients of Amir Hannan-who I believe took over Shipman’s practice-have open access, where they want, to their records, and he can extol the virtues of that. Other people have involved people in their care planning and it is going on. We are at a tipping point where people are embracing it. The other thing I would say about email consultation-the best description I have had of that-is from a doctor in The Veterans Administration, who said that, because they were doing email consultations with their patients, they saw their patients less often but knew them better. When I said that to a British doctor, they pointed out why: because you cannot interrupt an email.

Q306 Dr Wollaston: Very good. Chair, may I ask one separate point on the issue of healthcare assistants? We have talked a lot about the loneliness and isolation and improving longterm conditions. Are either of you able to say what is going to happen about the Cavendish review and putting in place some of the really necessary changes?

Norman Lamb: I still find it amazing that, in essence, someone can get a job with a care agency and go out and do pretty intimate caring work without any training. There is no effective mechanism to stop that. Even though the Care Quality Commission sets an obligation on providers to ensure that their staff are properly trained, there is no mechanism to really hold them to account on that. The Cavendish report, which was really welcome, proposed the idea of a very clear care qualification. We are amending the Care Bill to facilitate that, and, obviously, there has to be a consideration about the mass of existing care workers. You could not expect the whole system-the very many skilled care workers who do not need to-to do a qualification, but new people coming in, in my view, should have a qualification.

I also make the point that statutory services cannot do it on their own-either statutory services or private providers commissioned by statutory commissioners. There has to be this collaboration with people in their communities. Is it "Better Lives" they have in Cornwall? There is a fantastic programme there that involves volunteers working alongside the GP practice, just giving some companionship to people living on their own and giving them a bit of a life again. I think some GPs are sometimes reluctant, instinctively, to work collaboratively with volunteers, but they have embraced it and the results are quite dramatic in terms of reduced admissions and reduced dependency. So this sort of collaboration is necessary as well.

Q307 Valerie Vaz: I know we have gone all over the place, but, just to go back, every newborn baby gets a little red book and you put in their height, weight and vaccinations. So it cannot be too difficult, I suppose, to do something similar for longterm conditions. I want to go back, Minister, to the personal budgets. I am not quite sure whether they are cash limited, where the money will come from for the individual person and whether it would reflect, for example, changes in longterm conditions-say, if someone gets another one-or what would happen.

Norman Lamb: The bottom line is that a CCG currently pays for the care of someone who has NHS continuing care. The budget is quite substantial, as we know, for NHS continuing care. Instead of the CCG just paying for a care team to provide care to that individual without that individual having any choice about who the team is and how it is made up-and you hear awful stories about people who have been receiving social care from the local authority, their condition deteriorates, they become entitled to NHS continuing care and the NHS continuing care people say, "You can’t keep your existing team of carers. We are going to impose our own team on you and you have to take it"-this changes it so that the money that is currently being spent, in a sense, is put at the disposal of the patient. The patient is asked, "How do you want this resource that we are spending on your care spent?" It is not, in a sense, a new pot of money. It is spending the existing money that we are spending on people with chronic conditions-but spending it in a more effective way that meets their needs and their priorities.

Q308 Valerie Vaz: But the individual patients do not hold their own little budget, do they?

Norman Lamb: Right. There are two alternatives. You can have the personal health budget where the patient has a say but the money is deployed by the CCG, or you could have it as a direct payment, so they actually receive the budget and you have an agreed care plan, which is what happened in the pilots that we were talking about earlier with David. That choice is there. If someone’s care needs develop and another condition develops-depression, for example-then they could be reassessed and their budget could be increased.

Q309 Andrew George: I am sorry that I missed the earlier part, but following on from Sarah’s excellent question earlier about care assistants, when you consider all of the pressures in relation to home care workers in particular, there is a bottom-a floor-which I am afraid there may be a race to. If you consider that all of the policy, the mantra, the logic and the budgets are pushing patients out to their homes-and in the most extreme cases clearly they require some form of home care, some kind of home assistance-unless the Government step in with the minimum wage, as you were suggesting, Minister, with no training being required and minimal visit times in a very competitive environment with budget pressures from both the NHS and also local authorities, one can envisage this race to the bottom carrying on, at the very time when all of the policy logic is suggesting that is where a great deal more work needs to be done in terms of service delivery. Do you not agree that something needs to be done to raise the floor by suggesting regulations in relation to, for example, the living wage, minimum training and minimum visiting times in order to avoid the race to the bottom?

Norman Lamb: First of all, it is imperative that employers meet their obligations under the minimum wage.

Andrew George: Yes, of course.

Norman Lamb: I am extremely uncomfortable with this practice of not paying someone when they are travelling from one home to another. If there is a zero-hours contract, it might be that technically they can get around the normal understanding of the law in that way and we are looking at that. I have met with Vince Cable, who is undertaking a review of the rules on zero-hours contracts. There is this interplay between zero-hours contracts and the minimum wage that needs to be looked at. You referred to minimum training, and this is what we are seeking to do through the Cavendish recommendations and the amendment to the Care Bill.

The other issue here is the commissioning of home care. This practice of commissioning for slots of time is hopeless, in my view, and there is an urgent need to improve the quality of commissioning in social care. At the moment you might have a tendering exercise to deliver a home care service and the lowest bidder wins the contract, and it is that race to the bottom that you described.

In Wiltshire they have introduced commissioning to achieve outcomes, to achieve better results for people, to focus on quality. I was hearing from Paul Burstow in fact, who has visited there, that the care workers are receiving a salary. It is really interesting and a complete change of approach. If you incentivise the provider to improve someone’s mobility, to do introduce, for instance, telehealth and telecare into their provision, if you incentivise them to improve the person’s well-being, or perhaps work collaboratively with the voluntary organisation locally, and if the result of all of that is that dependency reduces, then there is a gain for the local authority. Most important of all, there is a gain to the person who is receiving the care.

We have worked with ADASS-the Association of Directors of Adult Social Services-to develop much better quality commissioning, a sort of template for commissioning for outcomes, for results for people, and that is the change that I think we have to make.

Q310 Chair: I am conscious that we are very close to the end, but when it was announced that you were coming to give evidence to us, Minister, a number of people wrote in to the Committee expressing concern about prosthetic services for limbless patients, which has been transferred, as I understand it, to NHS England. There is a belief in that community that those services, since 1 April, have been the subject of significant reductions. I do not know whether either of you are able to answer that question, but, if you are not, I would be grateful if you could write to us and set out the position.

Norman Lamb: I am concerned to hear that view expressed, because there is the potential, with NHS England commissioning it across the country, to introduce a common standard that should raise standards across the country to avoid the variability that has been there. If that is happening, it needs to be addressed, and we need to look at it. I do not know whether Martin has any thoughts to add.

Dr McShane: With the specialised commissioning, it may have been a dip-I do not know-but, prior to the creation of NHS England, there were about 30 specialist centres across England with no national commissioning, no standards and no coherence to that. There was variation in commissioning and funding and inequitable access. We have set up a clinical reference group to look for complex disability equipment. The work has commenced on that. We are working with 12 of the prosthetic centres to identify clear guidance, to study the potential number of patients that could benefit from, for instance, microprocessor limbs for the future as well. So it is not about taking a step back. It is about bringing about some equity, some standardisation and then some quality improvement into the future. That is my understanding of the situation.

Q311 Chair: Obviously it is a view that is not entirely shared in the affected community, so I think if either you, Dr McShane, or the Minister were prepared to meet people from that community, it may-

Dr McShane: NHS England would be delighted to.

Q312 David Tredinnick: I have one final question. We have been talking about personal budgets in the context of longterm care. Unless I missed something earlier on, are you looking towards taking personal budgets out to a wider health community-younger people?

Norman Lamb: Yes. As you may know, the first group that we have looked at is people who are on NHS continuing care. From October next year, they will have a right to have a personal health budget. I am very keen to expand this. There are some parts of the health service where it does not work, but for people with longterm conditions of various sorts it is a highly attractive proposition, from my point of view. I mentioned earlier that I think mental health is the area that I would most like to focus on next, because that capacity to give some power to the individual to determine their priorities is particularly strong in mental health.

David Tredinnick: Now one really last question.

Chair: Just one more.

Q313 David Tredinnick: I keep thinking of new questions to ask. Have you given any thought to whether there might be any conflict through personal budgets when a patient says, "Well, I want to do this, doctor," and the doctor says, "Oh, no, you don’t. I know best"?

Norman Lamb: There is potential conflict there. The interesting thing was that the pilots did not demonstrate that there was any great problem in reality. Probably the clinicians go on a bit of a journey as well in that they may start off from a position where they feel reluctant to lose control, as it were, but this idea of a partnership-and I am sure that Martin as a clinician absolutely sees that that is the way to do it-delivers better results for people.

Dr McShane: We underestimate the intelligence of the population. There is the evidence from Dartmouth, engaging people in managing and understanding their own needs, starting with the person rather than the condition, and then looking at what are their life goals-what do they want? We had a fabulous conference a few weeks ago, "Future of Health", where we had a people’s panel. We had 14 people with a variety of longterm conditions who sat in front of every speaker and they were the first to get to ask the speaker questions. I do not know why that came to mind today, but one of them, Jonathan, really resonated with me in what he said. He had had renal failure from the age of 16. He is now in his 50s. He said it took 20 years before anyone asked him his opinion. If you have had renal failure and been through the sort of management that he has had, who is the expert? I would have seen him as a clinician for maybe five hours a year. He lives with it for 24 hours a day; his carers are with him probably seven days a week, and I am there.

I think we need to respect the knowledge, insight and experience of the person with the longterm condition, and that is part of the culture change that I am trying to champion, but I am under no illusions about how difficult this is going to be.

Norman Lamb: The fascinating thing also is that people tend to be pretty good custodians of the money as well. They do not choose to go out and rashly spend it. They realise it is a scarce resource and use it to achieve their objectives but not in a-

Dr McShane: They are often harder than the medical profession.

Chair: This is the point in this evidence session where everybody has just one last question and I am going to draw it to a close. Thank you very much.

Q314 Rosie Cooper: Forgive me, though, I need to take advantage of the fact that I have got a Minister and NHS England here and ask you a question from left field, if I may. Does choice still exist in the NHS? Are patients able to choose their consultants as well as hospital, or are we using "Choose and Book" to make sure you cannot choose your consultant?

Norman Lamb: For me, choice absolutely exists.

Q315 Rosie Cooper: Consultants as well?

Norman Lamb: Yes, and in a way the whole discussion about personal budgets is completely about that. It is about power or choice. It is about putting the person in control, and that must always be the mantra.

Rosie Cooper: Thank you. I have evidence in Liverpool where again "Choose and Book" is used to not get you to the consultant you wish.

Chair: No more questions from left field, right field or centre field. Thank you very much.